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Original Research Article
AN ANALYTICAL STUDY OF CLINICAL FEATURES IN 100 CASES OF PITYRIASIS ROSEA
Saravanan N1, Sindhuja Ramasamy2, Murugan S3, Sridhar V4, Vanathi T5, Sarathchandran B6, G. P. Rekha7
1Associate
Professor, Department of Dermatology, Venereology and Leprology, Chengalpattu Medical College.
Professor, Department of Dermatology, Venereology and Leprology, Thanjavur Medical College.
3Assistant Professor, Department of Dermatology, Venereology and Leprology, Chengalpattu Medical College.
4Senior Resident, Department of Dermatology, Venereology and Leprology, Chengalpattu Medical College.
5Junior Resident, Department of Dermatology, Venereology and Leprology, Chengalpattu Medical College.
6Junior Resident, Department of Dermatology, Venereology and Leprology, Chengalpattu Medical College.
7Junior Resident, Department of Dermatology, Venereology and Leprology, Chengalpattu Medical College.
2Associate
ABSTRACT
BACKGROUND
Objective- Pityriasis rosea is an acute self-limiting disease, probably infective in origin, affecting mainly children and young adults
and characterised by distinctive skin eruption and minimal constitutional symptoms.
Aim of the study is to analyse the incidence of PR in Government General Hospital, Chengalpattu during the period from
November 2016 to January 2017, age and sex distribution, probable aetiological factor, symptoms of PR, morphological types and
distribution of PR, associated cutaneous findings and the course of the disease.
MATERIALS AND METHODS
100 self-reporting patients of age group 3 - 68 years with clinical features of Pityriasis rosea, who attended Dermatology OPD in
Chengalpattu Medical College over a period of 6 months from September 2016 to February 2017 were enrolled.
RESULTS
Out of 100 cases studied 27 (27%) were females and 73 (73%) were males. Prodromal illness prior to the onset of rash was
reported by 8 patients (8%), of whom 1 had fever alone, 1 had fever with history of jaundice and 6 had upper respiratory tract
infection. Itching was absent in 51 patients; 49 patients (49%) had itching, of whom most patients (46) had only mild itch. Herald
patch was present in 82 cases and absent in 18 cases. Both morphology and distribution were classical in 45% patients. In the
remaining 55%, atypical morphology and/or atypical distribution were observed. In our study, none of the patients had mucous
membrane or nail involvement. In 81% of patients, the lesions resolved within a period of 6 - 8 weeks. Active acne vulgaris is seen
in 5 patients, of whom 1 had eczema also and 1 had seborrhoeic dermatitis in addition. Post Acne scar is seen in 1 patient. Nevus
achromicus is seen in 1 patient. Epidermal nevus in 1 patient and combined hypo- and hyperpigmented moles in 1 patient.
CONCLUSION
Clinical diagnosis of Pityriasis rosea was easy based on the presence of Herald Patch, characteristic morphology and distribution
pattern of the lesions. The present study has revealed male preponderance. The age incidence was found to be high in adolescents
and young adults. No familial incidence was observed. Factors like wearing of new garments, stress and upper respiratory tract
infections were found to precipitate the disease in some cases. In most of the patients the lesions vanished without trace and postinflammatory hypopigmentation was noted in few patients, but none had hyperpigmentation. History of recurrence of the disease
was also present in one case. Histopathological study showed the features of nonspecific chronic dermatitis.
KEYWORDS
Pityriasis rosea, Herald Patch, Patch, Types, Association.
HOW TO CITE THIS ARTICLE: Saravanan N, Ramasamy S, Murugan S, et al. An analytical study of clinical features in 100 cases of
pityriasis rosea. J. Evolution Med. Dent. Sci. 2017;6(26):2142-2148, DOI: 10.14260/Jemds/2017/465
BACKGROUND
Pityriasis rosea is an acute self-limiting disease, probably
infective in origin, affecting mainly children and young adults,
and characterised by distinctive skin eruption and minimal
constitutional symptoms.
Financial or Other, Competing Interest: None.
Submission 22-02-2017, Peer Review 18-03-2017,
Acceptance 24-03-2017, Published 30-03-2017.
Corresponding Author:
Sindhuja Ramasamy,
Associate Professor,
Department of Dermatology, Venereology and Leprosy,
Thanjavur Medical College,
Thanjavur Medical College Road,
Thanjavur-613004.
E-mail: [email protected]
DOI: 10.14260/jemds/2017/465
The initial lesion, Herald patch, is followed several days to
weeks later by the appearance of numerous similarappearing smaller lesions, located along the lines of cleavage
of the trunk (Christmas tree pattern). Pityriasis rosea has
been reported in all races; the average annual incidence at
one centre was reported to be 0.16 percent. It is more
common between 10 and 35 years of age with equal sex
distribution or a slight female preponderance HHV-6 and 7
may play a role extensively in some patients with PR. The
various morphological types are macular, papular, vesicular,
lichenoid, pustular, purpuric, urticarial and Erythema
Multiforme (EMF) like. The lesions can occur anywhere on
the skin but it is rarely seen over the scalp, palms and soles.
After a period of about six to eight weeks, the lesions resolve
spontaneously leaving a residual hypo- or hyperpigmentation
without any complications.
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MATERIALS AND METHODS
The study was conducted at the Department of Dermatology,
Chengalpattu Medical College during the period from
September 2016 to January 2017. All the patients attending
the Dermatology Outpatient Department were screened and
patients with pityriasis rosea were enrolled. The clinical
diagnosis of Pityriasis rosea (PR) was made in each case
based on the morphology and distribution of the skin lesions.
During the first visit of the patients their name, age, sex,
address, occupation, income, etc. were noted. Complaints,
probable precipitating factors, prodromal illness, contact and
family history were also noted. A thorough examination of
both general and systemic was carried out. Complete
dermatological examination including the number, site, size,
morphology and distribution of primary and secondary
lesions followed by examination of palms and soles, hair, nail
and mucous membrane was carried out. Based on this,
patients were classified as classic or atypical variety of PR.
Investigations like haemogram, urine and motion
examination, skin scraping for fungus, blood VDRL, etc. were
done. All the patients were given symptomatic treatment and
followed up for a period of 3 months at weekly intervals. The
sequelae and complications if any were recorded. Data thus
obtained was complied, tabulated and statistically
summarised.
RESULTS
In our study, maximum incidence was noted in the age group
between 11 - 30 years (53%). The youngest patient in the
study was 3 years old and the oldest was 68 years old, which
is similar to that reported in literature. Both sexes are equally
susceptible according to some authors, while others quoted a
female preponderance.1 In our study, a male predominance
was observed. 1
Number of Males
Number of Females
73
27
Table 1. Sex Incidence
Age in Yrs.
Number of Cases
0 - 10
20
11 - 20
27
21 - 30
26
31 - 40
18
41 - 50
07
51 - 60
01
61 - 70
01
Table 2. Age distribution
Original Research Article
Age/Sex Distribution
Literature states that wearing of new garments may
precipitate or aggravate the disease. In our study, only 4
patients gave a history of wearing new garments prior to the
onset of the disease. Other provoking factors like and
psychogenic stress (2%) were also recorded in the present
study. Literature reports also indicate similar findings.2
Prodromal illness like upper respiratory tract infection
and malaise were seen in 8 patients (8%), similar to that seen
in literature. Literature reports herald patch to be seen in
50% - 90% of all PR patients,2 but in our study, it was noted
in 82% of patients. The location of the herald patch has been
seen to occur more frequently on the trunk (42%) followed
by upper limb and the thigh, which is similar to that reported
in literature. The herald patch which probably represented
the primary inoculation site of the virus according to various
authors was seen to occur over the covered areas of the
body.3 In our study also the herald patch was seen to occur
over the covered areas of the body in majority (66%) of the
patients.
The Herald patch is absent or undetected in about 20% of
cases. In our study also Herald patch was absent in 18%
patients. Rarely, the Herald patch may be double or multiple,
often close together. In our study also one patient had double
Herald patch close together.
Site of Herald Patch
No. of Patients
Chest
09
Abdomen
07
Umbilicus
02
Loin
08
Back
16
Shoulder
02
Scapula
01
Neck
04
Face
07
Upper limb
13
Thigh
09
Lower limb
04
(Knee and below knee)
Table 3. Distribution of Herald patch
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According to literature secondary lesions starts appearing
after an interval of 5 - 15 days (few hours to 2 months), in
crops at 2 - 3 days interval over 1 week to several weeks. In
our study after a varying period ranging from 1 - 30 days
following the appearance of the Herald patch, the generalised
eruptions followed. They appeared in crops, intermittently at
various intervals of 3 - 10 days.
The generalised eruptions have been found to manifest in
various morphological forms like papular, vesicular,
lichenoid, EMF-like purpuric, urticarial and pustular forms.4
In our study only papular, lichenoid, EMF-like lesions have
been observed.
Distribution of the secondary eruption over scalp, face
and penis has been reported to be uncommon.5 In our study
no scalp involvement was seen, but 1 patient had penile
lesions, 7 patients (7%) had lesions over the face.
Involvement of palm and soles is also uncommon and was
seen in 3 patients (3%).
Both morphology and distribution (typical bathing suit)
were classical in 45% patients. In the remaining 55% atypical
morphology and/or atypical distribution were observed.
Atypical Morphology
Papular PR
19
EMF-like PR
06
Lichenoid PR
02
Table 4. Atypical morphology of secondary eruption
Atypical Distribution
Inverse PR
11
Unilateral PR
01
Flexural
03
Table 5. Atypical distribution of secondary eruption
Atypical Sites
Face
07
Palm and soles
03
Distal limb
07
Penis
01
Thigh
02
Abdomen
01
Table 6. Atypical sites of involvement
Literature states that Unilateral Pityriasis rosea has been
reported. In our study, we had a case of Unilateral Pityriasis
rosea.
Literature states that mucous membrane involvement is
rare in PR, but may involve the oral and genital mucosa. In
our study, mucous membrane involvement was not seen.
According to literature pruritus is mild in 25% of cases,
50% mild-to-moderate and 25% had severe itching.1,6 In our
study 46% of patients had mild itching, 1% moderate and 2%
had severe itching, one of whom had history of swimming in
river water.
Grade
No. of Patients
Absent
51
Mild
46
Moderate
01
Severe
02
Table 7. Grading of Itching
Original Research Article
As reported in literature, most cases had a self-limiting
course and the disease lasted for 6 weeks.7 In our study, 91%
of patients had a self-limiting course of about 6 - 9 weeks. The
longest duration of 14 weeks was observed in 2 patients, one
had EMF-like PR, the other one had Classical Pityriasis rosea
with palmoplantar involvement.
In most of the patients (97%) the lesions vanished
without trace, which was similar to that in literature. Postinflammatory hypopigmentation was seen in 3 patients (3%).
However, hyperpigmentation was not seen like that reported
in literature.
Nail dystrophy had been reported by Silvers and
Glickman 1974, following Pityriasis rosea.8 In our study, none
of the patients showed any nail changes.
Literature reports that PR is associated with skin diseases
like atopy, seborrhoeic dermatitis and acne vulgaris.9 In our
study also association with seborrhoeic dermatitis and acne
vulgaris have been found.
Associated Skin Disease
No. of Patients
Acne vulgaris
06
Canites
03
Seborrhoeic Dermatitis
04
Nevus
03
M.C
01
L.N
01
Accessory Nipple
01
Eczema
01
Fibrous polyp
01
P. alba
01
Pediculosis capitis
01
Polymorphic light eruption
01
Striae distensae
02
Skin tag
02
Lipoma
01
Tinea versicolor
02
Tinea cruris
01
Traumatic fissure
01
Androgenic alopecia
01
Table 8. Associated skin diseases
Total Duration of the Disease
Total Duration
No. of Patients
6 weeks
27
7 weeks
23
8 weeks
31
9 weeks
10
10 - 14 weeks
09
Table 9. Total duration of the disease
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Original Research Article
In 81% of patients, the lesions resolved within a period of
6 - 8 weeks.
There was history of recurrence in 2 cases in our study.
These findings are also consistent with those in literature,
where recurrence has been seen in 2% of the cases.10
Figure 4. Typical Christmas Tree Appearance
Figure 1. Lichenoid PR
Figure 5. EMF-like PR
Figure 6. Unilateral PR
Figure 2. Flexural PR
Figure 3. Palmoplantar Involvement
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Figure 7. Inverse PR
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Original Research Article
in a proportion (10% - 44%) of unaffected individuals. Hence,
its role as a causative agent is yet to be proved.9,13
Probable Pathogenesis
HHV-7 and HHV-6 do not infect keratinocytes, but instead
infect CD4+ T cells within blood and are retained within these
cells in a latent form in most individuals. These cells are the
likely source of cell-free viral DNA found in plasma or serum
samples of patients with PR. They are also the likely source of
the scattered perivascular and perifollicular virus-positive
cells observed within some lesions of PR.
Figure 8. Papular PR
DISCUSSION
Pityriasis rosea (PR) of Gibert is defined as an acute, selflimiting disease, probably infective in origin, affecting mainly
children and young adults and characterised by a distinctive
skin eruption and minimal constitutional symptoms11 or a
self-limiting disorder characterised by the development of
asymptomatic erythematous scaly macules on the trunk.
Pityriasis means fine scales; rosea denotes rose coloured or
pink.
Epidemiology
The average annual incidence at one centre was reported to
be 0.16 percent (158.9 cases per 100,000 person-years).
Traore A et al in his cross-sectional study calculated the
prevalence of PR to be 0.6%.12 PR affects all ages from infants
to the elderly. It is uncommon in young children (less than 2
years) and elderly (more than 65 years).9 Most patients are
between the years of 10 and 35.9,10 The youngest reported
patient was three months old. The oldest reported patient
was 83 years old.10
Camille-Melchoir Gibert stated that females are affected
more often than males. Many studies have reported a slight
female preponderance, the most frequently reported male:
female ratio being 1: 1.2 to 1: 1.5.1,9 The reason for the
apparent female predominance is unknown.
In temperate zone, it is more common during winter. In
tropical regions, PR has been found to be more common
during hot and dry season.1
Aetiology
The evidence to support an infectious aetiology for PR is its
distinct clinical course. There is a primary skin lesion
followed by a secondary eruption with complete remission,
mostly within about eight weeks. This course of the disease is
similar to most of the viral infections. Moreover, many
patients do not have a second attack due to lifelong immunity,
a phenomenon which is commonly seen in many viral
diseases.
Herpes virus like particles has been found in 71% of PR
lesions. HHV6 and HHV7 have been suggested as the cause for
the eruption. The viral DNA is reported to be present in
peripheral blood mononuclear cells in the lesional and
unaffected skin of majority (80% - 100%) of individuals with
acute PR. HHV7 is detected slightly more frequently than
HHV6, but often both viruses are found. However, evidence
for the presence and activity of HHV-6 or HHV-7 is also found
Clinical Features and Diagnosis
The herald patch is the first lesion to appear in a PR patient. It
is a solitary round or oval lesion with a central wrinkled
salmon coloured area and a darker red peripheral zone
separated by a collarette of fine scaling. It may vary from 1-10
cm in diameter. The herald patch may occur anywhere on the
body, although the trunk and upper arms are its predilected
sites, i.e. in the areas covered by clothes.14 Rarely, it may be
on the face, scalp or the penis.9 When the plaque is irritated, it
may have an eczematous papulovesicular appearance. The
herald patch is seen in 80% of all PR patients.2 In another
study where a series of 127 patients were examined, 76%
were reported to have a herald patch.
Prodromal symptoms are usually absent.9 In a minority of
patients, flu-like symptoms have been reported including
general malaise, headache, nausea, loss of appetite, fever and
arthralgias.
The herald patch is followed by the secondary eruption,
the interval being 5 to 15 days.9 Two main types of lesions
are seen, one is the lesion of similar morphology as the herald
patch but smaller in size and the other is small, red, nonscaling papules that gradually increase in number and spread
peripherally. Both the forms can exist concomitantly. Old
lesions usually fade in two weeks, but new lesions will
continue to appear in crops at 2 - 3 days interval over a week
or 10 days.14 Each lesion shows circinate scaling where the
scales are attached only at the periphery, sometime resulting
in the characteristic “Hanging Curtain” sign.
In classical cases only the trunk and proximal aspects of
the extremities are involved, resulting in T-shirt-and-shorts,
high-necked short sleeved vest or bathing suit pattern.
Distribution may be distal to the elbow in 4.8% to 12% of
cases and distal to the knees or the elbows in 6% to 15.3% of
cases.9 The face is usually spared, except in children.9 Palms
and soles are spared in most cases. Palmoplantar
involvement in PR was reported by Klauder JV as early as
1924.5 On the anterior and posterior aspect of trunk, the
characteristic orientation of the secondary eruptions along
the skin cleavage line has been described in various terms as
Christmas tree pattern, inverted Christmas tree pattern and
fir tree pattern.
Pruritus is severe in 25% of patients; slight-to-moderate
in 50% and absent in 25% of patients. When PR is irritated,
itching is usually prominent.
The duration of the rash varies from 2 to 12 weeks, but
may last for as long as five months which is known as PR
perstans.7 Post-inflammatory hyper- or hypopigmentation
may also last for months, but usually the lesion vanishes
without trace.10
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Relapse may occur in 2% of cases after an interval of a
few months or many years. In a series of 826 patients, the
rate of relapse was noted as 2.8%.5
Up to 39% of patients with PR may have some atypical
features. Atypical features include atypical rash morphology,
rash size, rash distribution and site of the lesions.12 The
Herald patch may be absent or undetected in about 20% of
cases.9 There may be two or more patches. The primary
plaque may be the sole manifestation of the disease or only
one of two lesion. Atypical rash morphology includes papular,
vesicular, purpuric or haemorrhagic, urticarial, lichenoid and
EMF-like forms.9
Pityriasis rosea gigantea of Darier is rare characterised by
large sized plaques, which can have sizes up to the patient’s
own palm. Papular PR is the other extreme in the size of PR
lesions.15 It is more often seen in children. The secondary
eruption is numerous small papules 1 - 2 mm in diameter.8
Fewer and larger lesions often localised to the axillae or
inguinal region may be seen known as Pityriasis circinata et
marginata.5 Acrally distributed secondary rash is known as
PR inversus.16 Cases with strictly unilateral involvement have
been reported.17
Asymptomatic intraoral lesions in the form of tiny
punctate haemorrhages with pinhead erosion discrete and
slightly elevated lesions sometimes with superficial erosions
have been reported. Drugs including arsenic,11 tyrosine
kinase inhibitors, captopril,18 gold, isotretinoin, lithium, nonsteroidal anti-inflammatory agents, omeprazole18 and
terbinafine,19 have been implicated in causing PR-like rashes.
Lymphadenopathy may occur in patients with PR,
especially early in the course of the disease and in association
with flu-like symptom. Pitting of nails and onychodystrophy
after PR has also been reported.20 Other associated skin
diseases are atopy, seborrhoeic dermatitis and acne vulgaris.
Involvements of internal organs have not been documented.
No complications have been reported except for occasional
mild flu-like symptom.
Investigations
PR is a clinical diagnosis. Lesional histopathological changes
are non-specific. Taking a lesional biopsy thus cannot confirm
a diagnosis of PR. Histopathological examination was not
performed even in a recent clinical trial on PR, as it seldom
helps in diagnosis according to the investigators. For
adolescents at least, secondary syphilis should be excluded
with serology tests for all cases diagnosed with PR, especially
when the palms or soles are affected. Elevation of the
erythrocyte sedimentary rate, a slight decrease in the number
of T-lymphocytes and an increase in B-lymphocytes were
reported.5
Treatment
Since PR is self-limited, there is no need for active treatment
for all patients. Education and reassurance is enough for most
of the patients. Water, Soap, Wool and Sweating may cause
irritation and should be avoided in acute stages. New clothing
must also be avoided. For patients with mild pruritus, zinc
oxide or calamine lotion will suffice. For patients with
pruritus severe enough to disturb the quality of life, a course
of Erythromycin can be given in addition. Tab. Erythromycin
250 mg QID for 2 weeks; for children 25 - 40 mg/kg/day in
four divided doses for 2 weeks)21 along with antihistamines
Original Research Article
and mid potency topical corticosteroid for symptomatic relief
of pruritus. Systemic corticosteroids should be restricted to
adult patients with exceptionally recalcitrant and
symptomatic PR resistant to other treatments.22 For patients
with flu-like symptoms and/or extensive skin diseases, oral
Acyclovir 800 mg, 5 times daily for 1 week may hasten
recovery from disease.23 Phototherapy, ultraviolet radiation
in erythmogenic doses has been found to be useful. But postinflammatory, pigmentation at the site of the PR lesion may
be a complication.24 Dapsone has been used in severe
vesicular PR.25
CONCLUSION
Pityriasis rosea is a self-limiting skin disease. Clinical
diagnosis of Pityriasis rosea at the earliest presentation is
important to avoid unnecessary investigations and to give
reassurance about the self-limiting nature of the disease. The
practicing dermatologist should be aware of the various
clinical presentations of the disease. There is no need for
active treatment in most of the patients. The present study
has revealed male preponderance. The age of incidence was
found to be high in adolescents and young adults. No familial
incidence was observed. Factors like wearing of new
garments, stress and upper respiratory tract infections were
found to precipitate the disease in some cases. In most of the
patients, the lesions vanished without trace.
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Original Research Article
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